Cellulitis resident survival guide

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Cellulitis Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Dos
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mydah Sajid, MD[2]

Synonyms and Keywords: : Bacterial skin infection, Local skin infection.
To read the cellulitis microchapter click here.

Overview

Cellulitis is the inflammation of deeper layers of the skin including the dermis and subcutaneous tissue. It is mostly due to a bacterial infection. The bacteria usually invades the deeper layers after breaching the skin barrier. Common bacteria such as streptococcus pyogenes, staphylococcus aureus, haemophilus influenza type B, clostridium, streptococcus pneumoniae and neisseria meningitidis usually involve the lower limbs. It presents clinically with signs of inflammation such as redness, swelling, warmth and pain. Risk factors for cellulitis include a weakened immune system, diabetes, lymphatic obstruction, and varicose veins. It is recommended to first rule out deep vein thrombosis (DVT) with compression doppler ultrasound of the limbs and d-dimer level. Elevated levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and leukocytosis could be detected. It is required to check systemic signs of infection. It is treated conservatively with oral antibiotics in uncomplicated cases. Parenteral antibiotics are administered in patients with systematic symptoms and progressive lesions. Incision and drainage are done if discrete abscesses are present.

Causes

Life-Threatening Causes

No known life-threatening causes are included.

Common Causes

The cellulitis is bacterial in origin and caused by the invasion of bacteria through the skin barrier. The common causes are listed below.[1][2][3]:

Diagnosis

Shown below is an algorithm summarizing the diagnosis of cellulitis according to the Infectious Diseases Society of America guidelines.[4][5][6]

 
 
 
Patients present with the following symptoms:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform compression doppler ultrasound of the limb and D-dimer level
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive
 
Negative
 
 
 
 
 
 
 
 
 
 
 
 
Deep vein thrombosis (DVT) is likely.
 
DVT unlikely. High clinical suspicion for cellulitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess levels of inflammatory markers
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Raised erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and leukocytosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following signs of systemic or rapidly progressive infection?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform the following tests:

Treatment

Shown below is an algorithm summarizing the treatment of cellulitis.[7][5][1][8][9]

 
 
 
 
 
 
 
 
 
Does the cellulitis present with purulent discharge?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Are there any of the following present?
 
 
 
Incise and drain any discrete abscess:
  • Delay oral antibiotic therapy
  • Monitor patient for spontaneous resolution.
  • If response is inadequate then initiate oral antibiotic therapy
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
     
     
    No
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Initiate intravenous antibiotic therapy. The coverage of the microorganisms is determined by:
     
     
     
     
     
    Initiate Oral antibiotic therapy.

    The coverage of the microorganisms is determined by:

     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    No
     
    Yes
     
    No
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Infection most likely due to MRSA. Initiate
  • Vancomycin or
  • Daptomycin
  •  
  • Incision and drainage of discrete abscesses.
  • Send drained specimen for culture and susceptibility.
  • Start wide coverage empirical antibiotic covering MRSA, gram negative rods, anaerobes, and gram-positive organisms.
  • Regimens include:

     
    Assess patient's risk for infective endocarditis
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
     
    No
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
  • Incise and drain the discrete abscess
  • Send the specimen for culture and sensitivity
  • Initiate empirical antibiotics for MRSA. Regimens include trimethoprim-sulfamethoxazole or doxycycline or minocycline
  •  

    Dos

    Don'ts

    References

    1. 1.0 1.1 Raff AB, Kroshinsky D (2016). "Cellulitis: A Review". JAMA. 316 (3): 325–37. doi:10.1001/jama.2016.8825. PMID 27434444.
    2. Semel JD, Goldin H (1996). "Association of athlete's foot with cellulitis of the lower extremities: diagnostic value of bacterial cultures of ipsilateral interdigital space samples". Clin Infect Dis. 23 (5): 1162–4. doi:10.1093/clinids/23.5.1162. PMID 8922818.
    3. Swartz MN (2004). "Clinical practice. Cellulitis". N Engl J Med. 350 (9): 904–12. doi:10.1056/NEJMcp031807. PMID 14985488.
    4. Hook EW, Hooton TM, Horton CA, Coyle MB, Ramsey PG, Turck M (1986). "Microbiologic evaluation of cutaneous cellulitis in adults". Arch Intern Med. 146 (2): 295–7. PMID 3947189.
    5. 5.0 5.1 5.2 5.3 Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America". Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.
    6. Beltran J (1995). "MR imaging of soft-tissue infection". Magn Reson Imaging Clin N Am. 3 (4): 743–51. PMID 8564693.
    7. Miller LG, Quan C, Shay A, Mostafaie K, Bharadwa K, Tan N; et al. (2007). "A prospective investigation of outcomes after hospital discharge for endemic, community-acquired methicillin-resistant and -susceptible Staphylococcus aureus skin infection". Clin Infect Dis. 44 (4): 483–92. doi:10.1086/511041. PMID 17243049.
    8. Bobrow BJ, Pollack CV, Gamble S, Seligson RA (1997). "Incision and drainage of cutaneous abscesses is not associated with bacteremia in afebrile adults". Ann Emerg Med. 29 (3): 404–8. doi:10.1016/s0196-0644(97)70354-8. PMID 9055782.
    9. Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M (2007). "Videos in clinical medicine. Abscess incision and drainage". N Engl J Med. 357 (19): e20. doi:10.1056/NEJMvcm071319. PMID 17989377.
    10. Halilovic J, Heintz BH, Brown J (2012). "Risk factors for clinical failure in patients hospitalized with cellulitis and cutaneous abscess". J Infect. 65 (2): 128–34. doi:10.1016/j.jinf.2012.03.013. PMID 22445732.
    11. Hepburn MJ, Dooley DP, Skidmore PJ, Ellis MW, Starnes WF, Hasewinkle WC (2004). "Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis". Arch Intern Med. 164 (15): 1669–74. doi:10.1001/archinte.164.15.1669. PMID 15302637. Review in: ACP J Club. 2005 Mar-Apr;142(2):45
    12. Thomas KS, Crook AM, Nunn AJ, Foster KA, Mason JM, Chalmers JR; et al. (2013). "Penicillin to prevent recurrent leg cellulitis". N Engl J Med. 368 (18): 1695–703. doi:10.1056/NEJMoa1206300. PMID 23635049. Review in: J Fam Pract. 2014 Jan;63(1):E10-2
    13. Thornhill MH, Dayer M, Lockhart PB, Prendergast B (2017). "Antibiotic Prophylaxis of Infective Endocarditis". Curr Infect Dis Rep. 19 (2): 9. doi:10.1007/s11908-017-0564-y. PMC 5323496. PMID 28233191.